Part 2: My Health Care Instructions (page 4)

4-A

Part 3: My Hopes and Wishes (page 5)

5-A

Sometimes, our values inform not only what we want, but of what we don’t want. If you have some thoughts about how you would ideally like to die, please add them here.

5-B

If you are part of a faith community, please add in details of how we may contact them.

Part 3: Organ Donation, other wishes (page 6)

6-A

If you’re interested in organ donation, please be sure your agent is aware of this. Your agent would be responsible for arranging this at the time of death.

6-B

Be aware that if you’re interested in whole body donation, this is typically arranged well in advance and requires forms and documentation.

Part 4: Making this document legally valid (page 7)

7-A

This is the legally required part of the advance directive form in the State of Oregon.

Part 4: Making this document legally valid (page 8)

8-A

Fill in your name, date of birth your current address and initial one of the options.

KP recommends that you initial My Entire Life. If you change your mind about any part of this form, you are free to submit a new form. KP will use the most recent form you submit.

8-B

Appointment of health care representative (agent)

Write the name, address and telephone number of your representative, and an alternate (back-up) person in case your representative can’t be reached.

Choose someone who you have talked with about your wishes and you feel comfortable they would represent your wishes for you.

8-C

Limits (agent)

Write any specific instructions here. Some people write if there is someone specific that they DO NOT want to make decisions on their behalf. It is ok to leave this blank.

8-D

Initial the bottom of page 8. When you initial “I have executed…” this means you are completing the form.

Part 4: Making this document legally valid (page 9)

9-A

Life Support

Initial if you give permission for your agent to make decisions about life support.

If you want your agent to ONLY follow what you have written, leave this blank

9-B

Tube Feeding

Initial if you give permission for your agent to make decisions about tube feeding.

If you want your agent to ONLY follow what you have written, leave this blank.

9-C

Date on the top line. Sign on the bottom line. Signing and dating here confirms you are appointing a representative (agent).

9-D

Health care instructions

You may either give specific instructions by filling out items 1 to 4 OR fill out number 5 to give general instructions.

9-E

Initial one option under each question (1-4). You may choose to have all treatment available (first option), advice from the physician for your agent (second option), or chose to have no treatment. You will always be kept comfortable.

If you chose “as physician recommends” your agent and your physician will have a discussion about what could help you the most at that time.

Part 4: Making this document legally valid (page 10)

10-A, 10-B, 10-C

Initial one option under each question. You may choose to have all treatment available (first option), choose for your agent to act on advice from the physician (second option), or choose to have no treatment. You will always be kept comfortable.

If you choose “as physician recommends” your agent and your physician will have a discussion about what could help you the most at that time.

Part 4: Making this document legally valid (page 11)

11-A

General Instructions

Initial this option if you want no life support at all if you couldn’t speak for yourself and any of C1-4 were true (you were close to death, permanently unconscious, had an illness that would not get better or were suffering a lot).

You may choose to leave 1-4 blank and only initial this one if it represents your decisions of to be allowed to die naturally if any of those situations were true.

You may also choose to initial that you do NOT want life support on 1-4 AND fill out 5 as well, but it is not required.

11-B

Additional conditions or instructions

Write specific instructions here if you have any.For example: “no blood products” or “please play music for me” or “I only want life support for a maximum of one week,” etc.

11-C

Other documents

Most people will leave this section blank.If you are positively sure you have done a form before, please initial #2.If you aren’t sure, but you want to be extra safe, it is fine to initial number 2. Otherwise, leave this blank.

11-D

Write the date on the top line, sign on the bottom line

Signing and dating here confirms you are expressing your wishes for treatment in the above situations.

Part 4: Making this document legally valid (page 12)

12-A

Declaration of witnesses

Two witnesses MUST sign, date, and print their names. One of these two cannot be related to you. Think of people who know who you are – a neighbor, a friend, an acquaintance. KP employees cannot witness your forms.

12-B

Acceptance by health care representative

Your agent and back-up sign and date here. By signing and dating, your agent acknowledges that they understand your wishes and will represent them for you.

Be sure to mail KP a copy. Medical records will scan it in to your chart to make sure everyone at KP can see it.

Part 5: Next steps (page 13)

13-A

13-B

If you have a scheduled appointment, you may hand deliver a copy to your doctor. Or, alternatively, you may call your Health Engagement and Wellness Department for answers to questions, or information about returning your Advance Health Care Directive.

13-C

If you’d like to let your doctor know you’ve completed your Advance Health Care Directive and who you’ve chosen as your agent, you may send a secure message on kp.org.